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Massachusetts moving quickly to bring more providers into state’s push-pull HIE

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With the Golden Spike on October 16, Massachusetts began a new era of healthcare information exchange.   Now that we have momentum and the perfect storm for innovation with alignment of government, industry, academia, stakeholders, and funding,  we want to rapidly advance to the next phase.

Last week, while I was in China, a group from Massachusetts visited CMS in Baltimore to present the Phase 2 plans.   Here is the powerpoint they used.

A few key points

1.  After summarizing the accomplishments of our Phase 1 go live, they presented the sustainability model in detail (see slide 15-16).   The tiered pricing was developed based on several key principles (see slide 13-14) such as the need for large organizations which derive high value from the HIE to subsidize small practices which have limited resources and bandwidth for new projects.   The end result is that comprehensive HIE services cost a solo practitioner just $5/month.

2.  We know that "push" transactions are easiest from a policy and technology perspective, so Phase 1 was limited to use cases like PCP to Specialist, Provider to Public Health, and Hospital to PCP exchange.    We also know that "pull" transactions have a great deal of value by providing just in time delivery of community wide longitudinal health records (slide 21).   Pull models require significantly more complex technology and policy.    Pull models require a master patient index/record locator service and some means of recording consent to disclose records.   Rather than declare that the standards are not ready, the informatics challenges are too great, and the consent models are too complex, we're just moving forward with an aggressive timeline to get it done in 12-18 months.  (timeline is on slide 31)

3.  With Phase 1, we built a guiding coalition of providers, payers, patients, government, and employers to break down barriers and create community wide demand for the service.  Where there were standards gaps we filled them with simple SOAP-based XML exchanges (provider directory query/response).   In this next phase, we're going to do the same thing as outlined in slides 23-30.   Is there a simple set of standards for managing consent that is widely deployed in the industry?  No - we'll create one and refine it in actual production across thousands of users and millions of transactions.   Is there a simple set of RESTful interfaces for query/response retrieval of records across a complex community of non-affiliated organizations?  No - we'll create one and show that it works really well.   To date, our implementation guides for SOAP/REST XML exchanges are less than 10 pages each and do the job well.   Of course we'll use existing mature standards where they exist but we will not select implementation guides that fail the standards readiness criteria simply because the right standards have not yet been invented yet.

Over the next few months our push HIE will grow to scale as more providers and vendor products are connected to it.   Currently NEHEN, our administrative transaction HIE in Massachusetts, does over 100 million exchanges per year, so we're confident we can achieve and support clinical healthcare information exchange at large volumes.    We'll dive headlong into the pull HIE work very soon as the funding is finalized.   We'll broadly share our lessons learned, our policies, and our technology.

It's a great time for HIE in Massachusetts and I hope we can be a catalyst for wider push and pull HIE adoption in the country.

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Dr. John D. Halamka

By Dr. John D. Halamka

Dr. John D. Halamka is chief information officer and dean for technology at Harvard Medical School who writes at Life as a Healthcare CIO.
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